How does massage actually work?

My Career Pivot

Once I had finished massage school and completed my certification in Structural Integration, I took the tools and knowledge I had gained and applied it to the people who came to see me. Much of the time I got good results, but it began to feel like I was missing something. Like so many in this field I was obsessed with fascia and believed it to be the key to understanding the body and how to work as a bodyworker. But like so many things, as I learned more I realized my previous way of thinking was overly simplistic. First, I began noticing things that did not make sense about what I thought I was doing.

The seeds of doubt were planted early in my career when I read an article by Robert Schleip called, “Fascia as Sensory Organ“. He states, “The mechanism by which manual manipulation leads to muscle tonus change appears to involve the central nervous system loop.“ Here was a premier researcher in the study of fascia who admits that fascia can only be changed through the nervous system. It had been believed for decades since the days of Ida Rolf and her generation of osteopaths that fascia “melted” and “softened” with the force of our sustained pressure. Well, that might be the case, but it’s not because we have any direct influence over the fascia. If manual therapists were able to influence the fascia directly, the amount of force needed to create this change would create so much damage to the tissue that it would nullify any positive effect. This is because collagen, the building blocks of the fascial and interstitial system of the body, is extremely strong. This strength is crucial in order to transfer the tremendous amount of force needed to propel the body forward, to jump, or to lift a heavy object. This is something we simply don’t have the ability to change directly.

Greg Lehman is a Canadian physiotherapist and chiropractor. I got turned onto him because he spoke in a very casual, and at times, irreverent manner about therapists like himself who had got it wrong. I watched a short video (Frictionless interface and manual therapy) of his that scientifically dismantles a cherished belief held by so many structural integrators, Rolfers, and “fascia fanatics'' who claim to be able to do “myofascial release” and fascial therapy.” He argued that it is impossible to move the underlying fascial bags of the body by simply manipulating skin. He refers to a study which shows that skin is a fascial frictionless system. In other words, skin glides on top of underlying fascia. It does not move the underlying fascia as it glides on top of it. If you’ve ever handled a raw whole chicken, you’ll see that you can drag skin around the surface of the chicken without it influencing the underlying muscle or bones. Skin does not translate forces to the underlying fascia unless done perpendicularly into the body. If this were the case, then children everywhere would be walking around with disfigured faces after using their hands to make “smooshy faces”. It doesn’t make sense. We all know that you can distort the position of the skin on your face all you want - it will not stay that way. So why would certain manual therapists think that we could lengthen muscles through simply dragging the skin around? It is magical thinking at best. His website is a really great resource for anyone wanting to learn about up-to-date pain science in an easy-to-understand format. You can download his book, “Recovery Strategies: Your Pain Guidebook,” for free here (https://www.greglehman.ca/)

Then one day in 2016, while I was awaiting the birth of my daughter, I stumbled across a lengthy discussion on a now non-existent message board called SomaSimple where ideas around chiropractic, physiotherapy, and manual therapy were getting fleshed out by practitioners from across the world. The ideas they presented really challenged my way of thinking. Their argument was that the old model of a client's change being brought about by something the therapist does to them was outdated. Rather, through an understanding of the new and exciting research around pain-science, it was looking more like a client’s positive change was brought about mostly by a reduction in their perceived sense of threat in their environment (which can include their body). And that did have a lot to do with what a therapist did with their client, but probably not for the reasons we once believed. The client and their unique nervous system needs to somehow be involved and participate in order for lasting change to occur. This usually happens automatically in the course of therapy but if the therapist is adamant that they are doing something to them that will make them better, this process of participation can be cut-off.

I went through a process of doubt where I didn’t really know what I was doing anymore. I knew that the techniques I had learned worked, but suspected it wasn’t for the reasons I once believed. I began to seriously consider that it was really the nervous system that was responsible for my clients’ improvements all this time. I then went on to learn about Dermoneuromodulating from a Canadian Physiotherapist named Diane Jacobs. Diane Jacobs had been a major contributor to the discussion on the SomaSimple forum mentioned above. In her book, Dermoneuromodulating, she says something obvious but strangely overlooked by most manual therapists. She says, “skin is the only organ that we can actually touch” Her model of manual therapy focuses on the ways in which our touch influences the various billions of touch receptors in our skin. The quality of touch can then modulate the nervous system in ways that can turn down the volume in pain. This makes sense because the skin forms from the same tissue as the central nervous system during embryonic development. The outermost layer of an embryo is the ectoderm. This tissue then folds inward, to form the inner neural tube (this becomes the brain and spinal cord), leaving the outer ectoderm which later forms the skin.

The point is that the skin has everything to do with the nervous system, the spinal cord, and the brain.

I also began to realize something on my own. People come to see me primarily because they are in pain. They don’t come to see me because the fascia in their biceps femoris muscle needs lengthening. What I’m getting at is that I used to think that pain was the result of fascial distortions in the body. Now I see that pain is entirely its own thing. The body automatically does all the healing that is necessary early on with any kind of injury. Any residual pain after that is due to sensitization in the nervous system. So it would make sense to put all my focus on learning how to turn down pain in the body, rather than focusing on things that may have nothing to do with my client’s pain. Such as their left shoulder being slightly higher than their right, for example. A person can appear “unbalanced” in their body and still be pain-free and function well.

All this time I had been taught how my techniques influence bone, fascia, and muscle that I had forgotten about the only structure that can actually touch: skin. And if it’s the nervous system that ultimately decides the resting length of muscles and therefore the structure of the body, then it would make sense to target where the nervous system is getting the most feedback (the skin). Combine this with my new understanding that pain is a very complex product of nervous tissue perceiving itself under threat, or predicting danger; it would also make sense to think about how my techniques speak to the nervous system and how this can influence pain. And so a new paradigm of thinking about manual therapy took shape in my mind.

In actual practice, nothing substantial changed in the way I worked with my clients’ tissues. But it did change how I talked to them about their body. I moved very quickly away from telling my clients that their fascia or muscles were what we needed to change in order to help them with their pain or functioning. Afterall, our muscles receive their orders from the nervous system. By telling clients that they may have issues with muscular imbalances and fascial restrictions, I may have inadvertently encouraged their nervous systems to perceive their bodies to be more in danger than they actually were. And this nervous system hyper-sensitization would naturally increase pain. So I began to talk about increasing the feeling of safety and strength in my clients’ bodies. I reassured them that although their pain was indeed very real; much, if not all, of the healing that needed to take place in their actual physical tissues had taken place already (unless the injury was recent). Now all that is left for us to do is to increase their feeling of safety in their bodies.

So what would that look like? By gaining permission from the nervous system through specific activation techniques, my clients could increase their range of motion and let go of their belief that their bodies needed to stay limited in order to stay safe. And this change in thinking comes through the direct experience of their bodies moving in novel ways and feeling more vitality and sensation in their bodies. Greater movement and less protection (muscle hypertonicity) means that the nervous system has turned down the volume of pain receptors and pain perception from those receptors.

I now continue to learn more techniques which safely encourage novel movement, knowing that this is what builds a belief of resilience and safety in the nervous system. The end result is less pain, less “tightness”, and feeling more limber and vital. I have an arsenal of techniques I now use to gain permission from the nervous system to gently coax a greater range of motion from my clients’ joints. This looks a lot like stretching very specific muscles and joint articulations, but with participation from my clients who will push against my resistance in particular ways. Through this change in approach to my work I am getting better, more consistent results. And my clients come away with each session with a more accurate understanding of what their pain actually is - a signal that the perception of threat in their environment is present. Hopefully, we can learn to be less afraid of pain and see it more as simply a sensation and a signal. Less fear about that signal can actually decrease the volume of that signal.

The body is a very complicated and sophisticated piece of biology and our understanding of it is always changing. It’s vitally important that all practitioners in the healthcare field stay up to date and go through the uncomfortable process of changing their long-standing beliefs and attitudes for the sake of better outcomes for our patients and clients. I can confidently say I feel much better and more congruent in the way that I work with my clientele. It was a long, uncomfortable process. But it was worth it.